THE FAMILY CONVERSATION #4

Enriched Housing

Enriched Housing is defined as an adult care facility whose operator licensed to provide long-term residential care to five or more adults, primarily senior persons 65 years of age or older, in community-integrated settings resembling independent housing units. Residents live in an apartment setting, which includes a bathroom, living room, and kitchen, and they have access to a package of services such as meals, housekeeping, laundry/linen service, transportation, socialization and recreational activities, some supervision and personal care assistance.

There are two models of enriched housing in New York State:

• The Program Model, where the operator of an existing apartment building is licensed to provide housing and services, allowing aging tenants to continue living where they are instead of relocating to a higher-care facility.
  

• The Facility Model, where the developer of a new multi-unit facility is licensed to provide services to all residents, whose functional frailty requires the assistance of the program—but not a medical condition requiring 24-hour skilled nursing, nor the chronic need of assistance from another person.

Adult Homes

Adult Homes are defined by law as adult care facilities that provides long-term, supportive residential services, activities, and personal care to five or more elderly adults and non-elderly adults with disabilities. Adult homes provide a private or semi-private room, private or shared bath, all meals, housekeeping and laundry service and 24-hour supervision, Long-term personal care services are designed to enable residents to maintain good health and hygiene, to carry out the basic activities of daily living (ADLs) and participate in the ongoing activities of the facility.

Assisted Living Residences

Assisted Living Residences are certified adult homes or enriched housing programs that are additionally licensed by the state health department to provide ongoing care and services for persons who cannot live independently and need assistance in the activities of daily living (ADLs), but who do not require around-the-clock nursing care or extensive medical supervision.

A residence must provide or arrange for housing, daily food service, 24-hour, on-site monitoring, case management services, an individualized service plan for each resident, and personal care services in a home-like setting of five or more adult residents unrelated to the assisted living provider. Assisted living residences may offer each resident their own room, a small apartment or shared space with a suitable roommate. Residents share common areas, such as a dining room or living room. They frequently offer services like transportation, planned activities, exercise and wellness programs.

Assisted living facilities will either offer a social or a medical model. In the medical model scenario, an adjoining nursing or sub-acute or rehab center is available if a person needs more medical assistance. Some assisted living facilities have more residents who are wheelchair-users, but most of those people must be able to get out of their wheelchair with relatively little help.

Different licenses will tell you what services a community can offer and the level of abilities of its residents. Assisted Living certification categories include:

• Basic assisted living for residents who are medically stable;
• Enhanced assisted living for residents who require a higher level of care, such as assistance in walking, getting out of a chair, or using medical equipment: and
• Special needs assisted for residents who require specialized services to address needs such as Alzheimer’s.

New York State law and regulations guarantee assisted living residents certain rights and protections and define their responsibilities. A list of the Rights of Residents is available on the Department of Health website (www.health.ny.gov/facilities/adult_care/).

A nursing home may the best option for some seniors, especially if they’re experiencing chronic, long-term health problems that cannot be managed by custodial caregivers at home.

Nursing homes, or skilled nursing facilities, are New York State-licensed residences that can offer sub-acute care—a level of skilled medical care “between hospital and home”—provided under the supervision of trained individuals such as registered nurses. Examples of skilled nursing services include intravenous injections, tube feeding, physical therapy, changing sterile dressings on a wound, and monitoring vital signs and medical equipment.

Nursing homes provide a room, meals, help with activities of daily living, recreation, and general nursing care to people who are unable to take care of their daily living needs. They provide a 24/7 protective environment for people who do not need to be in a hospital setting, but who can no longer safely live on their own and require full-time monitoring. They are Medicare and Medicaid eligible; to be certified by Medicare, skilled nursing facilities must meet strict criteria and are subject to periodic inspections.

Before a person can be admitted to a nursing home, the state health department requires them to undergo an assessment to determine their physical, psychological, and social needs. The assessment forms are called the PRI (Patient Review Instrument) and the Screen, which must be completed by a certified public health nurse and are valid for a period of 90 days. Forms can be obtained at a hospital, from a nursing home, or from the county Department of Social Services.

If a person enters a nursing home directly from a hospital, the hospital’s social worker and discharge planner complete the PRI and Screen and make the necessary transfer arrangements, working closely with area nursing homes. If a patient enters a nursing home from their own home, the PRI and Screen can be obtained from the local Visiting Nurse Service or a certified home health care agency whose staff is qualified to make these evaluations. There are also professional individuals and agencies who specialize in long term care placement and are qualified to help families handle this process. (Ask in advance about their fees.)

Choosing a Facility

Patients and their caregivers should feel free to ask questions regarding their options in selecting a skilled nursing facility. A Patient Care Plan is formulated by a registered nurse, in conjunction with a physician, for the optimal, on-going care and rehabilitation for each nursing home resident. They try to place patients in facilities that can provide the needed care and are reasonably close to where the family resides.

New York State regulations require that a hospitalized patient on Medicaid who no longer needs inpatient hospital care be placed in the first available bed within 50 miles of the patient’s home. By telling the hospital which nursing homes to apply to, the patient or family can try to influence the location of the eventual placement.

There may come a time when caregivers recognize that a loved one is terminally ill and the family must choose the most appropriate health option for that person. For many people, that option may be hospice care.

Hospice is a comprehensive program of care, support and treatment for individuals who are terminally ill and have a life expectancy of six months or less. The goal of this program is to provide comfort for patients and their families, not to cure illness. Hospice care emphasizes pain control, symptom management, and emotional support rather than life-sustaining treatment. In most cases, care is provided in the patient's home, but it is also provided in hospice centers, hospitals, nursing homes and other long-term care facilities.

Hospice care is covered under Medicare, Medicaid, most private insurance plans, HMOs, and other managed care organizations. If a person qualifies for hospice care, they can get medical and support services, including nursing care, medical social services, doctor services, counseling, homemaker services, and other types of services. As part of hospice care, patients will have a team of doctors, nurses, home health aides, social workers, counselors and trained volunteers to help them and their family manage their illness.

People who are eligible for the Medicare Hospice Benefit must have Medicare Part A coverage and meet these provisions:

• a prognosis from their regular doctor (or nurse practitioner), as well as a hospice doctor, that the patient is terminally ill and not expected to live more than six months;
• the patient’s acceptance of palliative care for comfort, instead of care to cure their illness;
• the patient (or representative) signing a statement choosing hospice care instead of other Medicare-covered treatments for a terminal illness and related conditions.

Hospice and palliative care are not the same. Like hospice, palliative care is provided to individuals who are chronically or terminally ill, and aims to improve quality of life, pain and symptom management—but it may be provided in conjunction with curative therapies and is not based upon the patient’s life expectancy or prognosis. Hospice care is a special kind of palliative care for patients who are either not being helped by active treatment or for whom the burden of their treatment outweighs any benefits. Medicare coverage for hospice is for patients expected to live six months or less, although under a current Medicare pilot program, selected patients at hospices in 40 states are allowed to receive hospice care while also receiving curative treatments from their doctors.

Typically, a family member serves as the primary caregiver and, when appropriate, helps make decision to seek hospice care for the terminally ill individual, after talking with other family members and doctors. To find a suitable hospice provider, caregivers can consult the patient’s doctor, as well as find lists of potential providers from various organizations or government agencies (See Resources below.)

Hospices aren’t required to be certified or accredited, but many obtain accreditation from organizations such as the National Hospice and Palliative Care Organization and other groups that set standards for participating hospices. Medicare only covers hospice care if the provider is Medicare-approved. Original Medicare will cover everything an individual’s needs related to their terminal illness, as well as health problems that aren’t related to that illness.

Once a person’s hospice benefit starts, the hospice team develops a care plan that meets each patient's individual needs for pain management and symptom control. The interdisciplinary team usually consists of the patient’s personal physician; hospice physician or medical director; nurses; home health aides; social workers; counselors or clergy; speech, physical, and occupational therapists, if needed; and trained volunteers.

Members of the hospice team make regular visits to assess the patient and provide additional care or other services. Hospice staff is on-call 24/7. Among its responsibilities, the team:

• Manages the patient’s pain and symptoms.
• Assists the patient with the emotional and psychosocial and spiritual aspects of dying.
• Provides needed medications, medical supplies, and equipment.
• Coaches the family on how to care for the patient.
• Delivers special services like speech and physical therapy when needed.
• Makes short-term inpatient care available when treatment becomes too difficult to manage at home, or the caregivers need respite time.

Patients always have the right to opt out of hospice care at any time for any reason, for example, if their health improves. But even if a patient lives longer than six months, they can continue to receive hospice care, as long as a hospice doctor or medical director re-certifies that they’re terminally ill.

Hospice care is designed to provide comfort for terminally ill patients, but also support family caregivers. Hospice provides a level of care that may be difficult to get at a time when your loved one needs special care. It may require caregivers to learn new tasks, accept a different plan of care, and reflect their own family’s values during a deeply personal stage of life.

Hospice not only offers counseling during a loved one’s illness, but provides optional bereavement support for a year after the death of the family member.